From the College

Highlights

Hospitalist salaries spiked over last two years, SHM reports

SAN DIEGO—Hospitalist salaries rose significantly over the past two years even while productivity remained flat, according to the Society of Hospital Medicine’s (SHM) 2007-2008 survey reported at the group's annual meeting here last week.

The survey did not examine causes of the trends but researchers who presented the findings suggested that continuing hospitalist shortages or increased appreciation of the profession’s value may explain the rising salaries. Overall, they found that hospitalist compensation was closely linked to hours worked and number of patient encounters. That is bad news for nocturnalists, new hospitalists and women (who make up a disproportionate percentage of younger hospitalists), all of whom were found to have lower than average production and compensation.

Specifically, the survey found that the average hospitalist made $193,300 in 2007-2008 (a 13% increase over 2005-2006) while producing 2,447 encounters (a 4% decrease from the previous survey). Hospitalists whose income was based entirely on production (6% of the total) had higher production and compensation that those who received a flat salary (25%) or mixed compensation plans (69%).

The survey also looked at leaders of hospitalist groups and found them lacking in both administrative time and knowledge. More than a third of surveyed leaders did not know the annual expenses or professional fee revenues of their groups. Of those who did know, 85% were operating at a deficit. The leaders appear to be spending their time on clinical work instead of business management, the survey found. Group leaders reported the same quantities of encounters and hours worked as non-leaders, with slightly increased compensation (6% higher).

The SHM's sixth annual survey collected data from 440 hospital medicine groups, which researchers estimated represent about 15% of U.S. hospitalists. Because the results were not audited or verified, the findings should be used as a frame of reference only, the SHM researchers said. Their final report is expected to be available in print later this month.

ACP, others agree on how to measure, report physician performance

Leading medical, consumer, labor and employer organizations, including ACP, have agreed to a national set of principles about how to measure physician performance and report it to consumers.

The Patient Charter for Physician Performance Measurement, Reporting and Tiering Programs includes four primary criteria:

Measures should be meaningful to consumers and reflect the importance of patient-centered care;

Physicians and physician organizations should have input into these programs and the methods used to stratify performance. They should also have access to the information collected and be given notice before individual information is released;

Measures and methodology should be transparent, valid, accessible and understandable by consumers, physicians and other clinicians; and

Measures should be based on national standards, primarily standards endorsed by the National Quality Forum (NQF). Standards from other groups and organizations may be used, but they will be replaced by NQF standards when available.

Clinical trial populations don’t reflect everyone who gets ill

Patients enrolled in clinical trials don’t represent the diversity of the population afflicted with diseases, concluded a study group of medical researchers and patient advocates who have drafted ways to enlist more minorities into studies.

Despite federal and state policies, very few Americans actually take part in clinical trials, especially those at greatest risk for disease, according to a report issued by team of more than 300 public health officials, medical researchers and patient advocates.

For example, older Americans are routinely left out of clinical trials studying Alzheimer’s, arthritis and incontinence. And although more than 60% of all cancers occur in older Americans, only 25% of those taking part in cancer studies in 2003 were over age 65.

The study was conducted by the Chronic Disease Prevention and Control Research Center at Baylor College of Medicine in Houston and the Intercultural Cancer Council, and was funded by Genentech. They created the EDICT (Eliminating Disparities in Clinical Trials) Initiative, which recommended changes at the federal, state and institutional levels:

Implement more regulatory changes to improve enrollment of women and minorities;

Increase government and industry collaboration in research design and implementation to prompt more diversity;

Include community organizations in clinical trials;

Require investigators to include in their peer-review journal manuscripts an analysis of how the study's demographics correspond to the population that bears the greatest disease burden;

Train Institutional Review Boards to recognize how disparities manifest themselves in research protocols;

Avoid duplication of effort between and address disparities among government, non-profit and industry trials;

Enhance public education about clinical trials, including non-English speakers;

Implement "participant navigation," a new tool that helps patients keep their appointments and solves their non-medical problems; and

Assure insurance coverage of the costs associated with clinical trials.

Cardiology

Elderly patients may benefit from anti-hypertensive therapy

Treatment with the diuretic indapamide reduced the risk of fatal and nonfatal heart events in patients older than age 80, a recent study found.

In the study, 3,845 patients age 80 or older who had a sustained systolic blood pressure of 160 mm Hg or higher were randomized to receive either indapamide (sustained release, 1.5 mg) or placebo. Perindopril (2 or 4 mg), an angiotensin-converting-enzyme inhibitor, was added if needed to reach the target blood pressure of 150/80 mm Hg.

After two years, the mean blood pressure was 15.0/6.1 mm Hg lower in the active-treatment group than in the placebo group. Treatment was associated with a 30% reduction in the relative risk of fatal or nonfatal stroke, as well as relative risk reductions of 39% for death from stroke, 21% for death from any cause, 23% for death from cardiovascular causes and 64% for heart failure. The study appears in the March 31 New England Journal of Medicine.

The reduction in risk for stroke is consistent with previous studies, said the authors, but the reduction in death from any cause was new and unexpected. The significant lowering in the risk of heart failure is notable, they added, because hypertension is a major risk factor for heart failure, which is common in people over age 70.

An accompanying editorial noted that the patients in this trial were healthier than normal for their age and that more study is needed about the benefit, risk and expense associated with treating young, low-risk patients. However, the findings provide needed evidence that it is not too late to start anti-hypertensive therapy in very elderly patients.

Home-based defibrillators did not reduce risk of death in post-MI patients

Having an automated defibrillator (AED) at home did not reduce the risk of death for patients who had myocardial infarctions, a recent study found.

In the study, 7,001 patients who were not eligible for implanted cardioverter-defibrillators were randomized to respond in one of two ways in the event of a sudden cardiac arrest. One group would follow the standard procedure of calling emergency services and performing CPR while the other group would use an AED before taking those steps. Overall, mortality did not differ significantly between the two groups.

Overall, 450 patients died: 228 of 3,506 patients (6.5%) in the control group and 222 of 3,495 patients (6.4%) in the AED group, and only 160 of the deaths were from cardiac arrest. Of these deaths, AEDs were used in 32 patients; 14 of these received an appropriate shock and four survived to hospital discharge. The study is published in the April 1 New England Journal of Medicine.

Researchers noted several factors that might explain the results. The overall mortality rate was low, which may have been due to the effectiveness of modern drug therapy. Also, partners or companions of patients who experienced sudden events often failed to use an available AED once faced with a stressful situation.

The AEDs were effective when used, the authors said, but depended on someone witnessing the event and using the device. Overall, they concluded that placing the devices in homes does not appear to be an effective strategy.

In related news, the American Heart Association last week advised people who witness a heart attack to apply hands-only CPR, after dialing 9-1-1. Pushing hard and fast in the middle of the chest continuously can help save the life of a heart attack victim even without performing rescue breathing, said an April 3 AHA news release.

Only about a third of people who collapse from cardiac arrest get CPR help from bystanders, the AHA said. The new recommendations, published in the April issue of Circulation, are based on studies showing that hands-only CPR by an untrained bystander can be as effective as CPR with mouth-to-mouth resuscitation.

Simple in-office walking tests can help assess patients with PAD

Simple measures of lower extremity functional performance can help predict risk of mortality for people with peripheral arterial disease (PAD) and provide information beyond that provided by the ankle brachial index (ABI), a recent study reported.

Researchers took baseline measurements for the six-minute and four-minute walk at usual and fastest pace for 444 people with PAD. After 4.8 years, patients in the poorest baseline quartile of six- and four-minute walk performance had significantly increased total mortality and cardiovascular mortality compared with patients with the highest baseline performances. The results will appear in the April 15 Journal of the American College of Cardiology.

Current PAD guidelines suggest that ABI should be used to assess risk of mortality, with lower scores associated with increased risk of mortality, said the study. These results show that simple functional tests that can be performed in a physician's office with minimal time and effort may provide valuable additional information. Researchers speculated that the functional performance measurements may provide more sensitive information regarding the severity of PAD and the severity of concomitant cardiovascular disease, compared with ABI.

The findings suggest that optimal management of patients with PAD should include efforts to improve functional performance, the authors said. They added that further study is needed on whether improving functional performance will lower mortality risk.

ACP Journal Club

A recent meta-analysis found that vitamin D supplementation reduces all-cause mortality in adults and older individuals.

The review pooled 17 randomized controlled trials and one quasi-randomized controlled trial of vitamin D supplementation among various study populations with insufficient baseline vitamin D levels (serum 25-hydroxyvitamin D levels of approximately <20 to <30 ng/mL). Participants ranged in age from 33 to 106 years and were followed for a mean of 5.7 years. Mean daily dose of vitamin D adjusted for trial size was 528 IU.

There were 4,777 deaths in the 18 trials. Those who received vitamin D supplementation had an 8% relative risk reduction and a small absolute risk reduction, which translates to approximately one death prevented for every 150 patients who received supplementation. The study is abstracted in the March/April ACP Journal Club.

Vitamin D insufficiency affects 25% to 70% of patients, so achieving adequate blood levels may have an important impact on morbidity and mortality, said Journal Club reviewer Joel A. Simon, MD, of San Francisco Veterans Affairs Medical Center. Vitamin D supplementation is a reasonable approach for patients who have, or are at risk for, vitamin D insufficiency, Dr. Simon added. Current guidelines of daily vitamin D intake, ranging from 200-600 IU, may be too conservative, however; daily intakes ranging from 800-1000 IU may be necessary instead, he added.

Regulatory actions

Second U.S. measles outbreak this year strikes Arizona

The second measles outbreak in three months has occurred in the western U.S., after the disease was imported by a Swiss visitor to Arizona, the CDC said in an alert.

Nine confirmed measles cases were reported to the Arizona Department of Health Services between mid-February and March 31 in patients ranging from 10 months old to 50 years old. All but one of the patients were infected in a health care setting, and one of the adult patients is a health professional. There are two additional suspected cases, including one in a Colorado resident, and hundreds of contacts are being investigated, the CDC said.

San Diego had a similar outbreak in January and February, with 11 measles cases and a 12th patient who got sick in Hawaii after being exposed in San Diego. That outbreak was started by an unvaccinated child who had recently traveled to Switzerland, where a measles outbreak is ongoing, with transmission occurring in doctors’ offices and the community. Confirmed measles cases also have been reported in New York City and Virginia, but their origins were most likely Israel and India, respectively. In total, there have been 24 confirmed U.S. measles cases between January 1 and March 28, 2008.

Since people with measles usually come to doctors’ offices and emergency departments, providers should minimize transmission risks by following infection control practices and ensuring all staff have evidence of measles immunity, the CDC said. A suspected measles patient should be taken to a separate room and should wear a surgical mask, if it can be tolerated, the agency said.

Zanamivir associated with neuropsychiatric events

The prescribing information for zanamivir (Relenza) has been changed to reflect a warning about delirium and abnormal behavior in patients taking the drug, the FDA said last week.

The events, which occurred mostly in Japan and among pediatric patients, often had abrupt onset and rapid resolution. Providers should monitor patients closely for signs of abnormal behavior, and the risks/benefits of continuing treatment with zanamivir should be weighed if these symptoms occur, the FDA said in an alert.

Covidien recalls 32 lots of heparin on contaminant fears

Manufacturer Covidien is recalling 32 lots of pre-filled heparin syringes because two lots of the product contain a heparin-like contaminant, the FDA said.

No adverse events have been associated with the recalled lots of Heparin Sodium USP, a list of which is online. Physicians and patients should stop using the lots immediately, the FDA said.

There have been reports of serious injuries and deaths in patients who have used heparin injectable products which contained this contaminant and were made by other companies. Typical symptoms include anaphylactic-like reactions like low blood pressure, shortness of breath, nausea, vomiting, diarrhea and abdominal pain.

Cartoon caption contest

Put words in our mouth

ACP InternistWeekly wants readers to create captions for this cartoon and help choose the winner.

E-mail all entries to us by April 10. ACP staff will choose three finalists and post them in the April 15 issue of ACP InternistWeekly for an online vote by readers. The winner will appear in the April 22 issue.

Pen the winning caption and win a copy of "Medicine in Quotations," ACP's comprehensive collection of famous sayings relating to sickness and health, disease and treatment and a portrait of medicine throughout recorded history.

News for Internists

Latest issue of ACP Internist now online

The April issue of ACP Internist addresses telemedicine, the generation gap and achievable goals for patient’s self-management. Go online for the latest stories on:

Telemedicine. Modern medicine is dramatically cutting the distance that patients must travel, even for severe injuries. Consulting by telemedicine reduces delays, improves patient outcomes and brings health care to areas that otherwise wouldn’t have it.

Generation gap. Younger physicians enter medical school and their careers with a much different take on work-life balance than their teachers, mentors and employers. But each generation brings strengths to the workplace.

Self-management. The second in a three-part series on simple ways to engage patients in their own health care.

Medicare updates

ACP signs on to letter in support of Medicare legislation

The College has signed on to a joint letter in support of the “Save Medicare Act of 2008.” This legislation, introduced by Sen. Debbie Stabenow (D-MI), would replace pending Medicare cuts in July and January with positive updates to physician payments.

The letter, sent to all senators, expresses support for the bill and asks them to consider cosponsoring the legislation. Other signers of the letter include the American Academy of Family Physicians, the American College of Surgeons, the American Medical Association and the American Osteopathic Association.

Medicare payments to physicians are scheduled to be cut by 10.6% on July 1, 2008, and by another 5% on Jan. 1, 2009. The cuts to physician payments are the result of the sustainable growth rate formula. This formula ties physician payments to growth in the overall economy, rather than to the cost of providing care.

The new legislation would replace the July 1 cut with an extension of the 0.5% update that was enacted at the beginning of this year. The legislation also provides a 1.8% update for 2009. The joint letter points out that by providing 18 months of continuous relief from the payment cut problems, Congress will have the time needed to examine the current system and come up with a long-term solution.

ACP releases results of questionnaire to membership

Thirty percent of members who responded to a recent College questionnaire indicated that they have already made changes to their practices in anticipation of pending Medicare payment cuts, and nearly 9 out of 10 respondents indicated that they will do so if the scheduled July cut goes into effect.

Medicare payments to physicians are scheduled to be cut by 10.6 % on June 30, and by another 5% on Jan. 1, 2009. “Most patients—and as America ages, those numbers will include more and more Medicare recipients—receive their care from small-practice settings with 10 or fewer physicians. These physician practices are run like any other small business,” said Jeffrey P. Harris, FACP, president-elect of ACP. “Our members, internal medicine physicians, are concerned that the scheduled cuts will have such an adverse impact that many of them will be forced to close their practices or limit how many Medicare patients can be accepted.”

The questionnaire, e-mailed to members in February, sought specifics from practicing internists about how further payment cuts would affect their practices and their patients. Although not designed as a statistically valid survey, each of the reports from internists in practice provides a real-life glimpse into how patients may be affected by the Medicare cuts.

Many members said they would be forced to make changes to their practices, such as postponing capital purchases, reconsidering plans to purchase health information technology, and accelerating plans to retire. Almost a third of respondents said they would discontinue seeing new Medicare patients if the 10.6% cut goes into effect.

CMS releases final e-prescribing regulation

CMS last week released the final rule establishing new standards for e-prescribing. The new regulation provides standards for four types of information related to e-prescribing: formulary and benefits, medication history, fill status notification, and identification of individual health care providers.

Physicians will not be required to implement e-prescribing, but those who do will be required to follow the new regulation when using e-prescribing to send prescriptions for covered drugs for Part-D eligible individuals.

At the beginning of the year, ACP submitted comments to the administrator for CMS on the proposed e-prescribing rule. In those comments, Joseph W. Stubbs, FACP, chair of ACP’s Medical Services Committee, said, “ACP is well aware of the outstanding potential of e-prescribing to benefit the health of Medicare beneficiaries, and ultimately all Americans, and strongly supports CMS’ efforts to facilitate adoption of this technology throughout the health care system.”

Dr. Stubbs went on to mention that although the College supports the recommendations and believes that they are a positive step towards e-prescribing adoption, there are still significant barriers. These barriers include the costs associated with the necessary hardware, software, and implementation; and the limited evidence for a “business case” to implement this technology at the practice level.

ACP’s previous comments on the proposed regulation are available online.

From the College

Updated career resource center for internists

ACP Career Connection is now live on ACP's Web site with added features and new enhancements. Formerly known as the ACP Career Resource Center, Career Connection offers internists easy access to available jobs and resources for career enhancement.

Physicians can search for career openings from current issues of Annals of Internal Medicine, ACP Internist and ACP Hospitalist, as well as through “Online Direct” postings available exclusively online and updated weekly. New features allow physicians to create, edit and store their profile; upload and store a detailed CV if desired; apply for jobs online; search and save jobs; and manage their account. ACP Career Connection also offers career counseling, a residency database, links to listings of non-ACP CME, and conferences and meetings, as well as non-ACP physician products and services.

Additional career resources will be available at the Job Placement Center at Internal Medicine 2008, where attendees can get a jump on networking and job searching by posting a listing for $100 per page prior to the meeting or on site for $200 per page. All new Career Connection resources as well as information about the Job Placement Center at IM08 are available online.

Test yourself

A 24-year-old woman undergoes routine evaluation. She is pregnant at 12 weeks' gestation. Medical history is notable for homozygous sickle cell anemia (Hb SS). She has had multiple uncomplicated painful crises treated at home with hydration, nonopioid analgesia, and incentive spirometry. Following a physical exam and lab studies, what is the most appropriate management?

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